administration of intravenous drugs

Document name: Medicines Code: Administration of Intravenous Drugs Ref.: 703 Issue date: 11 February 2013 Status: Approved Author: Julian Hunt, Geoff Allen and Regina Brophy of 33

Medicines Code: Administration of Intravenous Drugs

Reference Number: 703

Author & Title: Julian Hunt, Nurse Consultant Geoff Allen, Risk Management Pharmacist Regina Brophy, Chief Pharmacist

Responsible Director: Director of Nursing

Review Date: 6 February 2016

Ratified by: Mary Lewis Acting Director of Nursing & Accountable Officer: Controlled Drugs

Date Ratified: 6 February 2013

Version: 11

Related Policies & Guidelines: All Medicines Code policies

Incident Reporting and Management Policy and Procedure; Including the Management of Serious Untoward Incidents


Index: 1. Introduction __________________________________________________ 3

2. Definitions and Competencies ___________________________________ 3

3. Summary ____________________________________________________ 5

4. Training and Assessment of Competence _________________________ 7

5. Administration / Recommendations for Safe practice / Checking_______ 8

6. Authorisation of Medicines for IV Administration___________________ 10

7. Unlicensed Medicines / Clinical Trial Medicine _____________________ 11

8. Cytotoxic Therapy ____________________________________________ 11

9. Verbal Orders for IV treatment __________________________________ 12

10. Routes for the Administration of IV Medicines _____________________ 14

11. Potency and Incompatibility of IV medicines ______________________ 15

12. Responsibilities of Clinical Pharmacists __________________________ 16

13. Procedure (See Detailed Guidelines Appendix 4) ___________________ 17

14. Incident reporting ____________________________________________ 19

15. Monitoring and Review ________________________________________ 19

16. References __________________________________________________ 20

Appendix 1: IV Drug Administration Manual Form 1 ___________________ 21



Appendix 4: Detailed Preparation Requirements ______________________ 24

Document Control Information ______________________________________ 31

Ratification Assurance Statement _____________________________________ 31

Consultation Schedule _______________________________________________ 32

Equality Impact: (A) Assessment Screening ____________________________ 33 Amendment History Issue Status Date Reason for Change Authorised 10 Approved January

2010 Planned Review Operational Governance

Committee 11 Approved 6 February

2013 Planned Review Mary Lewis

Acting Director of Nursing & Accountable Officer: Controlled Drugs


1. Introduction

1.1 It is essential that the reader adheres to terms, definitions, and processes as described both in the Medicines Code Policy and in the other relevant policies contained in the Medicines Code e.g. Prescribing Policy.

1.2 The purpose of this policy is to inform all practitioners of their responsibility in the safe and effective administration of intravenous (IV) medicines. The term IV refers to medicines administered using both peripheral and central cannulae.

1.3 The Medicines Management Policy lays down clear responsibilities for individuals in the implementation of the Policy. Failure to comply with the Medicines Management Policy may be regarded as misconduct and dealt with in accordance with the Trust’s Conduct Procedure.

2. Definitions and Competencies

Any practitioner or member of medical staff who administers IV medicines must ensure that they are competent to do so as assessed by either their line manager or professional supervisor. The nature of this assessment will be determined locally by their line manager or professional supervisor. In addition they must maintain evidence as part of their continuous professional development portfolio and are expected to identify any training needs in their personal development plan.

Practitioner The term practitioner includes medical staff, registered nurses, midwives, operating department practitioners, radiographers, cardiology, diagnostic and nuclear medicine technicians and all practitioners who administer IV medicines.

Nurse practitioners With nurse practitioners, the RUH nurse IV competence assessment framework is used

IV Trained practitioner

A practitioner who has satisfactorily completed the appropriate training for IV administration

Anaesthetists For anaesthetists, the Royal College of Anaesthetists Guidelines competence assessment framework is used.

Medical staff Any other medical staff who administers IV medicines must also ensure that they are competent to do so and maintain evidence as part of their continuous professional development portfolio

Medusa Medusa is the name of a UK hospital pharmacy medicines information collaborative database of IV and IM medicine monographs. It is available on line and has been customised for trust-specific information in addition to the standard text.


It contains more information than our current IV monographs which it will completely replace during 2013

Non-professional staff

Non-professional staff are doctor’s assistants, health care assistants, assistant practitioners to which some of this policy will apply. This list will be subject to periodic review by the Medicines Advisory Group

Assistant practitioners

Non-professional staff employed at Band 4 who provide support to professional staff.

ANTT Aseptic non-touch technique – see trust policy Double checking This is a method of checking to ensure low risk of error. The

accepted standard is to have two checks. In most instances independent double checking is where two individuals will check a medicine separately and then share their calculation to confirm accuracy. In some instances one individual may double check, but that person is required to check twice with a separation in time. A single check of a medicine for intravenous administration is not acceptable.

Intravenous Bolus Introduction of a small volume of medicine solution into the cannula or the injection site of an administration set. A bolus injection should be administered slowly over 3-5 minutes unless otherwise specified.

Intermittent Infusion Administration of an infusion over a set time period, either as a one-off dose or repeated at specific time intervals.

Continuous Infusion Intravenous administration of a volume of fluid with or without Medicines added over 24 hours or over a number of hours to achieve a clinical end point. The infusion may be repeated over a period of days. Large volume i.e. 25-1000ml or small volume infusions (e.g. 50ml of heparin) may be delivered continuously.

PCA Patient Controlled Analgesia is a continuous infusion via a PCA pump which allows the patient to administer preset bolus doses of the analgesic with a time lock out between doses.

Controlled Drugs in Schedule 2 and 3 of the Misuse of Drugs Act 1971

This comprises all drugs that the RUH trust requires to be stored in a Controlled Drug Cupboard. (see Controlled Drugs policy)


3. Summary 3.1 Where this policy applies to non-professional staff, individuals administering

intravenous medication (currently normal saline boluses only) will have received training and have their competency formally assessed. The administration of intravenous medicines will form part of their job description.

3.2 The administration of IV medicines forms an integral part of the registered nurse role. All registered nurses will be expected to administer IV medicines following appropriate training. Any practitioner who does not feel fully competent in the administration of any particular medicine must seek advice before administering that medicine

3.3 Administration of first and subsequent doses of IV medicines is covered by

this policy and all medicines should only be administered when they have been prescribed by an approved prescriber, using an official prescription chart.

3.4 All intravenous medicines should be administered by a competent IV trained

practitioner acting in accordance with the relevant RUH IV monographs. During 2013 these will be replaced by those on Medusa. Both these state the areas in which the medicines may be used and the competence of the staff who can administer them. These areas and competencies are formalised by the Medicines Advisory Group.

3.5 For medicines which do not have a RUH IV Monographs or marked ‘not approved’ on Medusa, these are likely to have already been approved for one-off use by pharmacy and may be given subject to pharmacy approval and using the Summary of Product Characteristics (SPC) as an additional check. (available on www.medicines.org.)

3.6 IV Medicines may be administered to neonates in the Neonatal Intensive Care

Unit in accordance with the Neonatal Formulary (NNF6 0 Jan 2011 (or latest edition) or British National Formulary for Children (BNFC) (latest edition)

3.7 When administering intravenous medicines to children the latest version of the

British National Formulary for Children must be used. 3.8 The intravenous Medicine Monographs are available on-line from Medusa.

The URL of the site is: http://medusa.wales.nhs.uk/?ID=6cdb33ff278efa39e355c8bd6814c9f82312 however there is a link in the hospital intranet dashboard as well as in the pharmacy section. This address has the embedded password, so anyone with internet access can use it. It cannot be used from WARD usernames.

http://www.medicines.org/

http://medusa.wales.nhs.uk/?ID=6cdb33ff278efa39e355c8bd6814c9f82312


3.9 In the trust header for each medicine there is an indication of the area/staff group that can give the medicine. These are:

• List 1.This is a general list, which covers all medicines that may be

administered in any ward or department within the Trust. For specific Medicines which may need to be given by bolus the monograph will identify when this must only be administered by a doctor or nurse consultant.

• List 2. Additional medicines that can only be administered by practitioners IV trained in Medicine administration in critical care areas i.e. Accident and Emergency Department, Coronary Care Unit (CCU), Critical Care Services (ITU and HDU), all Operating Theatres, Post Anaesthetic Care Units- Main Theatre & PAW (PACUs), Day Surgery Unit Recovery, Orthopaedic Recovery.

• List 2a Additional medicines that can only be administered by practitioners IV trained in Medicine administration in Advanced Care Areas – Medical Admissions Unit (MAU) and Chest Pain Unit (CPU).

• List 3 Additional medicines that can only be administered by practitioners trained in IV Medicine administration in Diagnostics, Radiology, and the Cardiac Catheterisation Lab

• List 4 Additional medicines that can only be given by RUH practitioners trained in IV Medicine administration in Central Delivery Suite and the Obstetric and Gynaecology wards of the Princess Anne Wing.

• List 5 Additional medicines that can only be given by practitioners trained in IV Medicine administration in William Budd Cancer Unit and Chemotherapy Out Patients

• List 6 Additional medicines that can only be given by practitioners trained in IV Medicine administration on the Paediatric wards (see note 2.5 and 2.6 above).

• List 7 Medicines that may ONLY be administered by practitioners trained in IV medicine administration in the Nuclear Medicine Department.

• List 8 Additional list of medicines which may be administered only by Doctors. • List 9 List of medicines for intra-arterial use only on specific designated areas

see 6.3 . 3.10 Exceptions to the restrictions on areas where medicines are to be given will

be allowed where it is not possible for the patient to be treated in that area. Initiation of therapy and responsibility for monitoring guidance must be under the responsibility of a member of staff who is from an area where the medicine can be given and who is experienced in its use. This role can be performed by Night Nurse Practitioners who are experienced in the use of the medicine and have evidence of competence.

3.11 Medicines in list 9 are not included on Medusa, so the trust will maintain a local list on the intranet. (see under Pharmacy, medicines guidance)

3.12 Staff may choose to print these monographs, either from the RUH IV Monograph site on the intranet, or from Medusa. However if they use one already printed it is their responsibility to ensure that it is the latest version.


4. Training and Assessment of Competence 4.1 Newly qualified or registered nurse practitioners will be expected to undertake

the approved Trust training for Administration of Intravenous medicines. This education and training will consist of theoretical knowledge and practical skills and will include a period of supervised practice and assessment of competence. Included in training will be specific training in methods of rigorous double checking.

4.2 For junior medical staff appointed to the Trust training must be undertaken

within the first month of employment. Prior to this time junior doctors may administer IV medicines but in accordance with individual accountability. They should ask for support and supervision by IV trained practitioners.

4.3 The training and assessment of nurse practitioners will normally be

undertaken six months after qualifying. Assessors will be appropriately trained and will carry out assessment of competency.

4.4 Ward and Departmental managers are responsible for ensuring that a regular

assessment of competence for each practitioner who administers IV fluids is carried out.

4.5 Agency Nurses must provide evidence of previous education and training in

IV medicine administration and evidence of competence assessment to their ward manager prior to administering IV medicines.

4.6 All newly appointed staff, including bank staff, must provide evidence of

previous education and training in IV medicine administration and undergo an assessment of competence prior to administering IV medicines. If evidence is not available, staff must undertake the Trust approved training for the administration of IV Medicines and assessment of competence. This is the responsibility of the ward or department manager.

4.7 Registered Children’s Nurses may, following the approved Trust training and

assessment of competence, administer intravenous medicines to children. All IV medicines across the Trust administered to children must be second checked. Outside the Children’s Unit (e.g. Emergency Department) the second checker must be a registered nurse. Only in the Children’s Unit the second check can be provided by a third year student nurse.

4.8 Radiographers may prepare and administer medicines for intravenous

administration under the supervision or at the request of an anaesthetist /surgeon or radiologist.

4.9 Nuclear Medicine technicians may administer pre-prepared IV

radiopharmaceuticals under the licence, supervision and training of a named Consultant Radiologist.

4.10 Certain specific non-professional roles may have the administration of

intravenous normal saline as part of their role (e.g. doctor’s assistants).


5. Administration / Recommendations for Safe practice / Checking

5.1. The administration of IV medicines must be carried out by an appropriately

trained individual.

5.2. “The administration of medicines is an important aspect of the professional practice of persons whose names are on the Council’s register. It is not solely a mechanistic task to be performed in strict compliance with the written prescription of a medical practitioner. It requires thought and the exercise of professional judgment...” Nursing and Midwifery Council - Standards for the Administration of Medicines’ August 2008 (reissued 2010)

5.3. Wherever possible two practitioners should check intravenous medication, one must be the person who then administers the drug. Independent checking is always required: a. Where the Designated Practitioner is instructing a student. b. Where the administering practitioner requests a second check. c. Where two practitioners need to be involved to support the interests of

the patient e.g. in Paediatrics. All medicines (including Intravenous medicines) administered to children aged 16 years or less (not on the Children’s Unit) must be checked by a second practitioner.

d. Where administering an IV medicine via an infusion pump a second check is required including the set pump rate.

e. Practitioners working in the Neonatal Intensive Care Unit. f. All chemotherapy including that being administered by the Intrathecal

route (see separate Intrathecal Policy and Procedure). g. All Controlled Drugs in Schedule 2 and 3 of the Misuse of Drugs Act

1971. Both must be Registered Practitioners except in the case of Pre-registration student nurses who if deemed competent are able to second check a controlled medicine.

h. Where a Potassium Chloride 15% Injection is being diluted before being administered (NPSA, 2002) – see Medicines Code - Prescribing, Storage, Ordering, Handling and Checking of Parenteral Potassium Solutions

i. Where local (departmental) preference or policy dictates. j. Where a complex calculation is involved in administering the medicine. k. Where a bolus of normal saline is being administered by a non-

professional staff member specifically trained in intravenous cannulation (check must be with a practitioner who is required to sign the Medicines Administration Record (MAR).

5.4. Where (apart from the list in 4.3) a second practitioner check is not possible, intravenous medications should be checked with another competent person. This could be a carer or the patient (himself or herself). Single-person double-checking with a time delay between each check may be appropriate in other (rare) situations. The standard is independent (two person) double checking.


5.5. It must be realised that full accountability for the correct administration of the medicine lies wholly with the administering practitioner, not the second checker.

5.6. Where two persons check; both must sign the Medicines Administration Record (MAR) as a record of administration.

5.7. The above recommendations apply to all aspects of intravenous medicine therapy including first dose administration and intravenous fluid regimes.

5.8. Intravenous medicines cannot normally be prepared, checked or administered by assistant grades (e.g. HCA’s), unless it is a specific part of that individuals role and identified within their job description.

5.9. It is recognised that there may be circumstances where practitioners are accustomed to using medicines from different lists and are working within areas where these lists do not apply. Medicines from different lists must not normally be administered in areas where the lists do not apply.


6. Authorisation of Medicines for IV Administration 6.1 The Drug Policy Group by means of the BCAP Joint Formulary approves

which medicines are on the formulary and where appropriate restrictions on prescribing apply.

6.2 The current RUH IV Monographs comprise those medicines that have been approved for use in the hospital and the practitioners and areas where they are permitted to be given. It is intended that Medusa will replace these monographs during 2013.

6.3 This information will be included in the header of each Medusa monograph.

However all medicines for which a monograph has been written will appear in the database, even though a number are not approved for routine use in the trust:: The formulary status of each medicine will be given in the header. Other medicines listed may only be used in controlled situations or as ingredients in manufacture, e.g. cytotoxic medicines, TPN ingredients.

6.4 The Medusa database is compiled from manufacturer’s licensed information.

If a product is being used outside the licence it may not be used in this way until a supplementary ‘local guide’ has been prepared and approved by the Medicines Advisory Group.

6.5 In addition the Medicines Advisory Group may produce a ‘local guide’ to clarify the licensed recommendations for example by producing a table to reduce the need for calculations, or to give the most commonly used dilutions used in the trust.

6.6 The procedure for requesting an additional ‘local guide’ or if the medicine is not included in Medusa is as follows:

• The request must be made on Form in Appendix 1 and signed by the consultant whose team will be using the guide. It should be sent to the Chair of the Medicines Advisory Group/Chief Pharmacist for inclusion at the next meeting.

• The Medicines Advisory Group will inform the requestor of the outcome.

• The Medicines Advisory Group will commission the production of a local guide to go into Medusa

Any new medicines or local guides will only be published on Medusa, but will be cross-indexed from the RUH IV Monographs intranet

6.7 Where a medicine has been procured for a specific unlicensed indication, it

may be given subject to pharmacy approval who will provide adequate information to the user for the safe administration of the medicine


7. Unlicensed Medicines / Clinical Trial Medicine

7.1 Unlicensed / clinical trials Medicines to be administered by the intravenous route must only be administered by medical staff. It is recommended that any clinician administering these medicines by the intravenous route has the medicine checked by a second professional prior to administration. An individual trial protocol may specify who is allowed to administer the medicine.

7.2 Medicines prescribed off label (i.e. licensed medicines for an unlicensed

indication or by an unlicensed route (e.g. intra-arterial) or in an unlicensed concentration) may only be administered within the terms of locally agreed departmental policies i.e. Critical Care Unit, Oncology, Cardiac Catheterisation Lab, X ray Department, Waterhouse Ward, and Endoscopy.

Where uncommon medicines are to be administered or no locally agreed policy exists pharmacy advice must be sought.

7.3 A separate section of the IV Drug Administration Manual (List 9) contains

details of medicines which are administered intra-arterially. This will continue to be maintained after the switch to Medusa.

8. Cytotoxic Therapy 8.1 The satellite pharmacy department will prepare all IV Cytotoxic Medicines. In

accordance with the national guidelines all IV chemotherapy treatments may only be administered by registered nurse practitioners or medical staff who have undergone further training specifically in the IV administration of Cytotoxic Medicines. – see RUH Trust Policy and Procedure Prescribing, Handling and Administration of Cytotoxic Medicines.

8.2 The practitioner must be assessed as competent.

8.3 The practitioner administering Cytotoxic treatments must have the medicine

checked by a second practitioner i.e. registered nurse, pharmacist, medical practitioner.


9. Verbal Orders for IV treatment 9.1 The Nursing and Midwifery Council (NMC) Standards for Medicines

Management (2007 and updated 2010) states that “A verbal order is not acceptable on its own. The fax or email prescription or direction to administer must be stapled to the patient’s existing medication chart. This should be followed up by a new prescription signed by the prescriber who sent the fax or email confirming the changes within normally a maximum of 24 hours (72 hours maximum – bank holidays and weekends). In any event, the changes must have been authorised (via text, email or fax) by a registered prescriber before the new dosage is administered. The registered nurse should request the prescriber to confirm and sign changes on the patient’s individual medicines administration record (MAR) chart or care plan.

9.2 The standards document continues: “In exceptional circumstances, a medical

practitioner may need to prescribe remotely for a previously unprescribed medicine, for example, in palliative care or remote and rural areas the use of information technology (such as fax, text message or email) must confirm the prescription before it is administered. This should be followed up by a new prescription signed by the prescriber who sent the fax/email confirming the changes within normally a maximum of 24 hours (72 hours maximum – bank holidays and weekends). The registrant is accountable for ensuring all relevant information has been communicated to the prescriber and s/he may refuse to accept a remote prescription if it compromises care to the patient. In this instance she should document accurately the communication that has taken place”.

9.3 Verbal orders should only occur in exceptional circumstances. In this

trust that is interpreted as an emergency situation.

9.4 An emergency is defined as a situation where there is immediate risk to life and limb of the patient and no medical practitioner can immediately attend. An emergency situation is where failure to act may be perceived as a failure in a practitioner’s “duty of care”.

9.5 It is not appropriate to accept verbal orders as a convenience

9.6 Where a verbal order is accepted the incident must be reported through the

critical incident risk reporting system

9.7 If a verbal order is taken, the registered practitioner must adhere to the procedure in the Medicines Code, Prescribing of Medicines -. • Only in exceptional circumstances should medicines be administered on

verbal order of a Medical Practitioner and for ONE dose only. • A reason why the Medical Practitioner is unable to come to the

ward/department and write a prescription should be documented by the nurse in the patient’s clinical record.


• Controlled Drugs must NOT be authorised as a verbal order. • A verbal order can only be accepted for a drug that has been previously

prescribed and administered (on this hospital admission). • The Registered Nurse must clarify the process with the Prescribing

Medical Practitioner explaining their role to supply a written prescription within 8 hours.

• The Registered Nurse must listen to the message and repeat the message back. (The numbers 13-19 can be misheard as 30-90 therefore the dose must be repeated separate numerals e.g. one, three for 13).

• An email fax or text message confirming the verbal order must be received prior to administration of the drug. If an email or a fax it must be printed and attached to the medicines administration record until the prescription is signed by the prescriber, when it should be filed in the clinical records. Where a text message is received the telephone number from which the text is received should be recorded in the medical notes, along with the number to which the text message was sent. The precise wording of the text should be recorded in the clinical record. A second nurse should check the content of the fax, email or text message. (Note; text messaging is not an ideal way of transmitting clinical information and is not preferred).

• The medication may then be administered, or the dose adjusted as per the verbal instructions.

• The Registered Nurse must then make a record of the medication, dose, route and time on the ‘Once Only’ section of the Patient’s Medication Record, stating clearly that it is a verified verbal order.

• The checking nurse should also sign the medication record • The Registered Nurse must refer back to the Registered Medical

Practitioner if the patient has either deteriorated or show no sign of improvement and needs medical assessment


10. Routes for the Administration of IV Medicines 10.1 IV medicines may be administered by the following routes: • Peripheral cannula / butterfly • Central lines – all types • Implanted devices (see below) Specific training, knowledge and experience may be required for specific line types

guided by local / departmental procedure. This training includes administration via Y site connectors.

10.2 IV medicines may be administered in the following ways:

• Fast intravenous injection (bolus/push) • Slow intravenous injection (slow bolus) • Intermittent infusion (by gravity or pump or burette chamber) • Continuous Infusion (by gravity or pump or burette chamber) • PCA – Patient Controlled Analgaesia Infusion

See Appendix 4 10.3 The practitioner may only administer medicines via the methods for which

they have received education and training. 10.4 Where medicines need to be given using a syringe pump or volumetric

infusion pump, the practitioner must have received education and training in the use of that equipment.

10.5 When IV medicines are being administered via a pump as an infusion the

infusion must be checked within15 minutes of commencement then at each medicine round unless otherwise directed in the monographs. The infusion must also be checked at each shift handover.

10.6 Changing of IV infusion lines must be carried out every 72 hours unless the

following applies 10.6.1 Giving a lipid emulsion e.g. (Propofol, Total Parenteral Nutrition (TPN))

the line must only be used for 24 hours and must be discarded at the end of infusion.

10.6.2 If a medicine is being administered via an intermittent infusion the line must be changed at every dose.

10.6.3 For blood administration the line must be changed at least every 12 hours.

Each line should be labelled with date and time of setting up (in order to facilitate line

changing)


10.7 Where medicines have been added to bags, mini bags or syringes an intravenous additive label (available from pharmacy) must be completed and attached to the bag or syringe. The following information must be included: • Patient’s name and Hospital number • Medicine name/ Dose/Batch number/Expiry date and time • Date and time Medicine added • Details of diluents, including batch number and expiry date • Signature of administering practitioner and checker

N.B. Dialysis lines must not be used for IV therapy unless specific advice has

been sought from the renal physicians, Critical Care Services (ITU and HDU) or the Bath dialysis centre.

11. Potency and Incompatibility of IV medicines 11.1 Medicines administered by the IV route have a more immediate and

potentially greater effect than those administered by other routes. There is also a risk of incompatibility between medicines and intravenous solutions. Clinical Pharmacists or the Medicines Information department will advise on compatibility and incompatibility.

11.2 When adding and mixing medicines the monographs must be checked to

ensure there is no incompatibility. Medicines must not be added to the following: • Blood, plasma, and blood products. • Parental nutrition regimes • Mannitol • Sodium bicarbonate • Medicines prepared as an emulsion (e.g. propofol)

11.3 A Sodium Chloride 0.9% flush, (except where incompatible) should be

administered before and after giving any intravenous medicines including those fluids listed above (in 10.2).

11.4 Any IV flush should be prescribed. This is now pre-printed on all prescription

charts. They may also be administered according to a Patient Group Direction.

11.5 IV medicines must be administered or added to intravenous solutions

immediately following reconstitution. Delay may result in degradation and loss of potency and microbial growth.

11.6 The practitioner (or appropriately trained non-professional) who is to

administer the medicines must prepare the medicines for use. Medicines must not be pre-prepared for another practitioner to administer unless that person is present or there are specific written protocols agreed by the pharmacy and department staff.


12. Responsibilities of Clinical Pharmacists

12.1. Pharmacists are responsible for monitoring both the prescribing and the administration of medicine therapies, alerting prescribers and other health care professionals to potential problems.

12.2. This is achieved by:

a. Checking and reviewing the appropriate selection of specific medicines

and medicine regimens (dose, route, frequency, administration method and dilution, compatibility and the duration of therapy)

b. This is endorsed by signing and dating the Medicines Administration Record (medication chart) (MAR) in accordance with the Pharmacy Endorsement Standards.

c. Recording and documenting interventions made and their outcomes.

d. Ensuring that the risks of medicine errors are minimised throughout the

process from prescribing, dispensing to administration.

e. Responding to specific enquires raised by health care professionals regarding all aspects of medicine therapies including:

• Method of administration • Diluents and infusion fluids • Medicine stability • Delivery systems e.g. pumps • Medicine compatibility • Rate of administration • Contraindications and side effects • Interactions • Unlicensed Medicines and their use

f. Training of the members of the healthcare team as appropriate

g. Advising on appropriate treatment for the management of

extravasations and preparation of anaphylaxis boxes in accordance with written guidelines

h. The RUH IV Drug Administration Manual will be replaced by Medusa

during 2013. Medusa is subject to regular updates practitioners must always use the current version (online) for reference. For amendments and local policy updates see section 6


13. Procedure (See Detailed Guidelines Appendix 4) 13.1 Read and understand the prescription, if in doubt check with another

practitioner or the prescriber. Check that the prescription is dated and signed as well as clear and legible

13.2 Check medicine in accordance with RUH IV Monographs (or Medusa when

implemented in 2013 )and the Medicines Code - Administration of medicines policy and procedure and any locally agreed policy. This may involve a second person to check the Medicine.

13.3 The practitioner giving an intravenous medication must know the therapeutic

use of the medicine to be administered, its normal dosage, side effects, precautions and contra-indications (NMC, 2010)

13.4 The practitioner must be aware of the patient’s plan of care / treatment

pathway (NMC, 2010) 13.5 Where contra-indications to the administration of a medicine exist, the

prescriber, or another authorised prescriber must be notified immediately. 13.6 The practitioner giving an intravenous medication must be aware of the

medicine’s normal dosage, side effects, contra-indications and any special precautions required by checking the monograph, the BNF or package insert. Also note any special instruction on the Medicines Administration Record (medicine chart) (NMC, 2010)

13.7 Check:

• Medicine, Medicine dosage and prescribed route for administration • expiry dates of Medicine , diluents, infusion fluid required • ensure no faults in vials ampoules and equipment,

13.8 Use Aseptic Non-Touch Technique (ANTT) throughout 13.9 Prior to preparation wash hands, apply alcohol hand rub and wear latex (or

latex-free) gloves 13.10 Prepare Equipment as follows

• Plastic tray for each patient • Syringes of required size • Needles • Swabs • Medicines and diluents as prescribed (check to ensure that storage

instructions for medicine have been met)


13.11 Where an intravenous insulin infusion is being prepared, it is important to use an insulin syringe to draw up the insulin dose which can then be mixed with appropriate diluent in a larger syringe for infusion. UNDER NO CIRCUMSTANCES SHOULD THE INSULIN DOSE BE DRAWN UP USING ANY OTHER TYPE OF SYRINGE.

13.12 Prepare medicine, checking for any discoloration or cloudiness. Preparation of

substances for injection in advance of their immediate use or administration of medication drawn into a syringe or container by another practitioner when not in their presence is not acceptable (NMC, 2010)

13.13 Check patient identity with Medicines Administration Record (medication chart) (MAR)

13.14 Check that the patient consents to receiving the prescribed intravenous

medicines 13.15 Check for allergies or medicine sensitivity 13.16 Check patency of cannula and IV lines 13.17 Check cannula site for signs of infection, extravasations or phlebitis If VIP

score is ≥ than 2 then the cannula must be removed and new one re-sited prior to drug administration.

13.18 If appropriate, stop infusion and flush cannula with (prescribed) Sodium

Chloride 0.9% unless incompatible or unless otherwise stated

13.19 Administer medicine at the correct rate, in accordance with the monograph

instructions, using the correct delivery systems including pumps lines and filters.

13.20 Observe for adverse reactions, monitoring the patient as appropriate. For some IV medicine administration this may involve documenting vital signs assessment and early warning score (EWS).

13.21 Flush cannula with (prescribed) Sodium Chloride 0.9% (where compatible)

and / or re-start infusion. 13.22 Record and sign for medicine administration on the patient’s Medicines

Administration Record (medication chart) (MAR). If a medicine is not administered, the appropriate code must be entered in the MAR and where required an entry in the clinical patient record. The prescriber or another authorised prescriber must be notified immediately.

13.23 Ensure that all sharps and non-sharp waste are disposed of safely and in

accordance with Trust Infection Control policies.


14. Incident reporting

If an incident has occurred or an error observed, there is a duty to take action to prevent any harm (or further harm) to the patient. If an incident may have affected the patient he/she must be assessed and immediate actions taken to assure safety. The prescriber must be informed immediately and the senior nurse (on call, if immediate line manager is not available). All incidents/ errors should be reported using the current RUH Trust incident reporting process. (see 213 - Incident Reporting and Management Policy and Procedure; Including the Management of Serious Untoward Incidents) Any omitted or delayed doses must be recorded on the last page of the prescription, together with the reason, and if necessary and contact made to advise medical staff of situation.

The objective is to identify changes needed to prevent future errors. The risk team will forward copies of all medication errors to the Chief Pharmacist for review. The Medicines Advisory Group will also review prescribing incidents as part of an on-going review of medication incidents, identify any trends and propose actions to reduce errors in future.

15. Monitoring and Review This policy for medicines reconciliation and the use of patient’s own medicines will be monitored via the following processes:

• The Specialty review of monthly Incident Reports, including medications provided by the Risk Management Team;

• The Medicines Advisory Group will review medication incidents and findings of investigations on a quarterly basis, to identify trends and key risks, proposing actions to reduce errors in the future;

• Medicines Reconciliation is audited monthly as part of the South West Quality and Patient Safety Programme.

This policy will be in effect for three years, unless it is considered that some changes are needed. Prior to the third anniversary of the policy the author will be asked to review it and make any necessary changes prior to further ratification.


16. References British Medical Association and the Royal Pharmaceutical Society of Great Britain. “British National Formulary for Children”. RPS Publishing. London. Latest edition available on http://www.bnf.org and follow link British Medical Association and the Royal Pharmaceutical Society of Great Britain.. “British National Formulary”. RPS Publishing. London. Latest edition available on www.bnf.org

National Patient Safety Agency. (2002). “Patient Safety Alert: Identifying and Reducing Risks from Potassium Chloride Concentrate Solutions”. NPSA. London

National Patient Safety Agency. (2007): “Promoting safer use of injectable medicines: A template standard operating procedure for prescribing, preparing and administering injectable medicines in clinical areas”. NPSA. London. Northern Neonatal Network. NNF6 (2011). “Neonatal formulary: Drug use in Pregnancy and the first year of life”. Sixth edition. BMJ Books. London Nursing and Midwifery Council (2007) “Standards for Medicine Management”. NMC. London (reissued 2010)

http://www.bnf.org/

http://www.bnf.org/


Appendix 1: IV Drug Administration Manual Form 1

IV Drug Administration Manual This Form may be photocopied.

1. Request for an existing Medicine to be included on additional lists.

(Complete the box below and return to the Chief Pharmacist/Chairman of the Medicines Advisory Group, Pharmacy Department, RUH)

2. Changes to an existing local practice monograph or notification of error). (Complete the box below and return IMMEDIATELY to the Chief Pharmacist/Chairman of the Medicines Advisory Group, Pharmacy Department, RUH)

Name of requester: Bleep/Phone Number: Ward/ Department of requester: Medicine: Date of request: New list requested: Reason for request: Signature of ward / department Manager:

Name of practitioner: Bleep/Phone Number: Ward/ Department of practitioner: Medicine: Date of notification: Details of error or change in local practice: Signature of ward / department Manager:



IV Drug Administration Manual

Form 2 This Form may be photocopied.

Authorisation for Administration of Unlicensed Medication

Medicine: Usual Dose Range: Route of Administration: Indication: Names of authorised IV trained Practitioners:

Advice and agreement from Pharmacy sought Signature of Pharmacist:

Declaration by Consultant I understand that does not have a Product License under the Medicines Act. I take responsibility for the administration of this Medicine by the above named IV trained practitioners, if it has been prescribed on my authority and is given in accordance with the recommended procedure.

Signature of Consultant Date



IV Drug Administration Manual Form 3

This Form may be photocopied.

Authorisation for Administration of Medication not covered by existing monograph

Medicine: Usual Dose Range: Route of Administration: Indication: Patient name: Hospital Number Names of authorised IV trained Practitioners:

Advice and agreement from Pharmacy sought Signature of Pharmacist:

Declaration by Consultant

I understand that does not have a Product License under the Medicines Act. I take responsibility for the administration of this Medicine by the above named IV trained practitioners, if it has been prescribed on my authority and is given in accordance with the recommended procedure. This declaration allows administration of the Medicine to the patient named above.

Signature of Consultant Date


Appendix 4: Detailed Preparation Requirements

General 1. Read all prescription details carefully and confirm that they relate to the patient to

be treated. 2. Cleanse hands as per trust policy. 3. Ensure that the area in which the medicine is to be prepared is as clean,

uncluttered and free from interruption and distraction as possible. Ideally, preparation should take place in an area dedicated to this process.

4. Gather all materials and equipment: sharps bin for waste disposal, medicine

ampoule(s)/vial(s), diluent, syringe(s), needle(s), alcohol wipes, disposable protective gloves, clean re-usable plastic tray. Check the following:

• expiry dates; • damage to containers, vials or packaging; • that medicines were stored as recommended, e.g. in the refrigerator.

5. Beware of the risk of confusion between similar looking medicine packs, names

and strengths. Read all labels carefully. 6. Check that:

• the formulation, dose, diluent, infusion fluid and rate of administration correspond to the prescription and product information;

• the patient has no known allergy to the medicine • you understand the method of preparation.

7. Calculate the volume of medicine solution needed to give the prescribed dose. Write the calculation down and obtain an independent check by another qualified healthcare professional, where calculations are complicated. Calculation examples may be included in individual medicine monographs. It is good practice to record complex calculations in the clinical record.

8. Prepare the label for the prepared medicine. Blank labels should have the drug

name written on them to avoid accidental confusion of multiple syringes in a tray. 9. Cleanse your hands according to trust policy. 10. Use a 70% alcohol wipe to disinfect the surface of the plastic tray. (Ensure that

plastic tray is socially clean; if not sure then a detergent wipe should be used first). Allow wiped tray to dry.

11. Cleanse hands with alcohol hand rub as per trust policy 12. Assemble the syringe(s) and needle(s). Open wrappers carefully and arrange all

ampoules/vials, syringes and needles neatly in the tray as per ANTT guidelines.


13. Use an aseptic ‘non-touch’ technique, i.e. avoid touching areas where bacterial

contamination may be introduced, e.g. syringe-tips, needles, vial tops. Never put down a syringe attached to an unsheathed needle.

14. Put on non-sterile examination gloves (latex rubber or nitrile as per personal

preference. Consider whether patient has latex allergy. 15. Prepare the injection by following the manufacturer’s product information or local

guidelines.

Withdrawing solution from an ampoule (glass or plastic) into a syringe 1. Tap the ampoule gently to dislodge any medicine in the neck. 2. Snap open the neck of ampoules, using a disposable ampoule snapper if

required. 3. Attach a needle to a syringe and draw the required volume of solution into the

syringe. Tilt the ampoule if necessary. 4. Invert the syringe and tap lightly to aggregate the air bubbles at the needle end.

Expel the air carefully. 5. Remove the needle from the syringe and fit a new needle or sterile bung. 6. Label the syringe. 7. Keep the ampoule and any unused medicine until administration to the patient is

complete to enable further checking procedures to be undertaken. 8. If the ampoule contains a suspension rather than solution, it should be gently

swirled to mix the contents immediately before they are drawn into the syringe. Withdrawing a solution or suspension from a vial into a syringe

1. Remove the tamper-evident seal from the vial and wipe the rubber septum with

an alcohol wipe. Allow to dry for at least 30 seconds. (Some vials, such as those containing insulin are designed for multiple use and a tamper proof seal is not appropriate).

2. With the needle sheathed, draw into the syringe a volume of air equivalent to the

required volume of solution to be drawn up. 3. Remove the needle sheath and insert the needle into the vial through the rubber

septum. 4. Invert the vial. Keep the needle in the solution and slowly depress the plunger to

push air into the vial.


5. Release the plunger so that solution flows back into the syringe. 6. If a large volume of solution is to be withdrawn, use a push-pull technique.

Repeatedly inject small volumes of air and draw up an equal volume of solution until the required total is reached. This ‘equilibrium method’ helps to minimise the build-up of pressure in the vial. For some vials it may be appropriate to use a spiked filter to allow the syringe to be filled from the vial. It is not acceptable to equalise pressures in syringe and vial by using an unfiltered needle.

7. With the vial still attached, invert the syringe. With the needle and vial uppermost,

tap the syringe lightly to aggregate the air bubbles at the needle end. Push the air back into the vial.

8. Fill the syringe with the required volume of solution then draw in a small volume

of air. Withdraw the needle from the vial. 9. Expel excess air from the syringe. Remove the needle and exchange it for a new

needle or a sterile bung. 10. The vial(s) and any unused medicine should be kept until administration to the

patient is complete. 11. If the vial contains a suspension rather than solution, it should be gently swirled

to mix the contents, immediately before they are drawn into the syringe.

Reconstituting powder in a vial and drawing the resulting solution or suspension into a syringe

1. Remove the tamper-evident seal from the vial and wipe the rubber septum with

an alcohol wipe. Allow to dry for at least 30 seconds. 2. Withdraw the required volume of diluent (e.g. water for injections or sodium

chloride 0.9%) from ampoule(s) into the syringe, as described above. 3. Inject the diluent into the vial. Keeping the tip of the needle above the level of the

solution in the vial, release the plunger. The syringe will fill with the air which has been displaced by the solution (if the contents of the vial were packed under a vacuum, solution will be drawn into the vial and no air will be displaced). If a large volume of diluent is to be added, use a push-pull technique (see above).

4. With the syringe and needle still in place, gently swirl the vial(s) to dissolve all the

powder, unless otherwise indicated by the product information. This may take several minutes.

5. Withdraw the required volume of solution from the vial into the syringe as

described.


6. If a purpose-designed reconstitution device is used, the manufacturer’s instructions should be read carefully and followed closely.

Adding a medicine to an infusion

1. Prepare the medicine in a syringe using one of the methods described above. 2. Check the outer wrapper of the infusion container is undamaged. 3. Remove the wrapper and check the infusion container itself in good light. It

should be intact and free of cracks, punctures / leaks. 4. Check the infusion solution, which should be free of haziness, particles and

discolouration. 5. Where necessary, remove the tamper-evident seal on the additive port according

to the manufacturer’s instructions or wipe the rubber septum on the infusion container with an alcohol wipe and allow to dry for at least 30 seconds.

6. Depending on the type of infusion container it may be appropriate to consider that

if the volume of medicine solution to be added is more than 10% of the initial contents of the infusion container (more than 50ml to a 500ml or 100ml to a 1litre infusion), an equivalent volume must first be removed with a syringe and needle.

7. Inject the medicine into the infusion container through the centre of the injection

port, taking care to keep the tip of the needle away from the side of the infusion container. Withdraw the needle and invert the container at least five times to ensure thorough mixing before starting the infusion.

8. Do not add anything to any infusion container other than a burette when it is

hanging on the infusion stand since this makes adequate mixing impossible. 9. Before adding a medicine to a hanging burette, administration must be stopped.

After the addition has been made and before administration is re-started, the contents of the burette must be carefully swirled to ensure complete mixing of the contents.

10. Check the appearance of the final infusion for absence of particles, cloudiness or

discolouration. 11. Label the infusion according to Trust policy.

Diluting a medicine in a syringe for use in a syringe-driver

1. Prepare the medicine in a syringe using one of the methods described above. 2. Draw the diluent into the syringe to be used for administration by the pump or

syringe-driver. Draw in some air (slightly more than the volume of medicine needed) and remove the needle.


3. Hold the diluent syringe upright. Insert the needle of the syringe containing the

medicine into the tip of the diluent (administration) syringe and add the medicine to it. Alternatively, a disposable sterile connector may be used to connect two syringes together directly.

4. Check the following:

• the total volume of injection solution in the syringe is as specified in the prescription and that the infusion can be delivered at the prescribed rate by the administration device chosen;

• the rate of administration is set correctly on the administration device and according to the manufacturer’s instructions.

5. Fit a sterile bung to the administration syringe and invert several times to mix the

contents. 6. Remove the blind hub. Tap the syringe lightly to aggregate the air bubbles at the

needle end. Expel the air and refit the bung. 7. Carefully check the syringe for cracks and leaks and then label it especially

noting the requirements specific to syringe drivers. 8. Check that the rate of administration is set correctly on the device before fitting

the syringe, priming the administration set and starting the infusion device. The rate of infusion set should be independently checked wherever possible.

Labelling injection and infusion containers

1. All injections should be labelled immediately after preparation. For syringes intended for immediate push (bolus) administration by the person who prepared them, labels should be used if more than one medicine is being used or if a flush and one medicine is being given. Under no circumstances should an operator be in possession of more than one unlabelled syringe at any one time, nor must an unlabelled syringe be fitted to a syringe driver or similar device.

2. Labels used on injectable medicines prepared in clinical areas should contain the

following information: and • name of the medicine; • strength (dose); • route of administration; • diluent and final volume; • patient’s name; • date and time of preparation; • expiry date and time; • initials of the practitioner preparing the medicine • initials of second checker


If the injectable has been prepared for immediate administration as a bolus by a practitioner, a simple label with the name of the drug only is appropriate. A label to distinguish “flush” from other medications is required.

3. Place the final syringe or infusion and the empty ampoule(s)/vials(s) in a clean plastic tray with the prescription for taking to the patient for administration. Administration of an injectable medicine

Before administering any injection 1. Check all the following:

• patient’s name, hospital number and date of birth (check identity bracelet) • prescriber’s signature; • the approved medicine name; • the dose and frequency of administration; • the date, time and route of administration; • the allergy status of the patient.

2. Also check, where relevant: • Approved name and formulation of the medicine; • concentration and total quantity of medicine in the final infusion container

or syringe; • name and volume of diluent and / or infusion fluid; • rate and duration of administration; • type of rate-control pump or device(s) to be used; • the age and weight of any patient, where relevant; • date on which treatment should be reviewed.

3. Check that the medicine is due for administration at that time and has not already been given.

4. Cleanse hands according to local policy. 5. Assemble everything you need including any flushing solution(s) needed. 6. Explain and discuss the procedure with the patient. Obtain consent for

administration of medicine. 7. Check any infusion already in progress. It should be free of haziness, particles

and discolouration. 8. Check that an appropriate access device is in place. Flush it immediately before

and after administration of a medicine, and between doses of different medicines administered consecutively, according to local policy. Also check the administration site for signs of leakage and Visual Infusion Phlebitis (VIP) score


Administration of injections – general

1. Check infusions. They should be should be free of haziness, particles and

discolouration. 2. Use ANTT at all times. 3. Attach administration sets to infusion containers carefully, using the technique

appropriate to the type of container. 4. Prime the access device (three way tap, needless connector if used) according to

local policy immediately before starting an infusion. 5. Before adding a medicine to a hanging burette, administration must be stopped.

After the addition has been made and before re-commencement, the contents of the burette must be carefully swirled to ensure complete mixing.

After administration 1. After completion of an intermittent infusion, flush the access device according to

local policy, disconnect any giving sets no longer used and dispose of according to Trust policy

2. Ask the patient to report promptly any soreness at the injection site or discomfort

of any sort. 3. Document administration on Medicines Administration Record (medication chart). 4. Discard the empty ampoules / vials from which the injection was prepared and

any unused medicine. Ampoules or vials should never be used to prepare more than one injection unless specifically labelled by the manufacturer for ‘multi-dose’ use.

5. Re-check the administration site for signs of leakage, VIP score and continue to

monitor the patient, contents of the infusion container and the rate of infusion according to local policy.

6. Check that arrangements for monitoring fluid balance or clinical parameters have

been made. Ensure that relevant documentation is made available for subsequent regular monitoring to take place.


Document Control Information

Ratification Assurance Statement

Dear Mary

Please review the following information to support the ratification of the below named document.

Name of document Medicines Code: Administration of Intravenous Drugs

Names of authors: Regina Brophy Julian Hunt Geoff Allen Chief

Pharmacist Nurse Consultant Risk Management

Pharmacist

I, the above named author confirm that:

• The Policy presented for ratification meets all legislative, best practice and other guidance issued and known to me at the time of development of the Policy;

• I am not aware of any omissions to the Policy, and I will bring to the attention of the Executive Director any information which may affect the validity of the Policy presented as soon as this becomes known;

• The Policy meets the requirements as outlined in the document entitled Trust-wide Policy for the Development and Management of Policies (v4.0);

• The Policy meets the requirements of the NHSLA Risk Management Standards to achieve as a minimum level 2 compliance, where applicable;

• I have undertaken appropriate and thorough consultation on this Policy and I have documented the names of those individuals who responded as part of the consultation within the document. I have also fed back to responders to the consultation on the changes made to the Policy following consultation;

• I will send the Policy and signed ratification checklist to the Policy Coordinator for publication at my earliest opportunity following ratification;

• I will keep this Policy under review and ensure that it is reviewed prior to the review date.

Signature of Authors: Date: 4 February 2013 Name of Person Ratifying this policy: Mary Lewis

Job Title: Acting Director of Nursing & Accountable Officer: Controlled Drugs

Signature: Date: 6 February 2013

To the person approving this policy:

Please ensure this page has been completed correctly, then print, sign and post this page only to: The Policy Coordinator, John Apley Building.

The whole policy must be sent electronically to: [email protected]

mailto:[email protected]


Consultation Schedule

Name and Title of Individual Date Consulted Francesca Thompson, Director of Nursing March 2009 Jan Lynn, Assistant Director of Nursing March 2009 Gareth Howells, Assistant Director of Nursing March 2009 Sharon Preston, Assistant Director of Nursing March 2009 Mark Bonson, Clinical Skills Facilitator October 2008 Jenny Chen March 2009 Julie Blackman March 2009 Regina Brophy, Chief Pharmacist January 2009 Alex Lucas March 2009 Julian Hunt August 2010 Mary Lewis, Acting Director of Nursing January 2013

The following people have submitted responses to the consultation process: Name and Title of Individual Date Responded Sharon Bonson, Assistant Director of Nursing January 2013 Liz Cowdrey, Clinical Co-ordinator January 2013

Name of Committee/s (if applicable) Date of

Committee Medicines Advisory Group January 2009 Operational Governance Committee October 2009 Senior Nurses Group September 2008 Operational Governance Committee January 2010 Policy Group November 2010 Medicines Advisory Group December 2010


Equality Impact: (A) Assessment Screening To be completed when submitted to the appropriate Executive Director for consideration and approval. Person responsible for the assessment: Name: Job Title:

Does the document/guidance affect one group less or more favourably than another on the basis of:

Yes/No Comments

Race Yes No Ethnic origins (including gypsies and travellers) Yes No Nationality Yes No Gender (including gender reassignment) Yes No Culture Yes No Religion or belief Yes No Sexual orientation Yes No Age Yes No Disability (learning disabilities, physical disability, sensory impairment and mental health problems)

Yes No

Is there any evidence that some groups are affected differently? Yes No

If you have identified potential discrimination, are there any valid exceptions, legal and/or justifiable? Yes No

Is the impact of the document/guidance likely to be negative? Yes No

If so, can the impact be avoided? Yes No What alternative is there to achieving the document/guidance without the impact? Yes No

Can we reduce the impact by taking different action? Yes No

If you answered NO to all the above questions, the assessment is now complete, and no further action is required.

If you answered YES to any of the above please complete the

Equality Impact: (B) Full Analysis

administration of intravenous drugs

Documents